By Gary M. White, MD
A pearly telangiectatic papule with crusting is classic. A bit of seborrheic dermatitis is seen in the nasal crease.
Basal cell carcinoma (BCC) is the most common type of cancer in Europe, Australia and the US, and is caused primarily by chronic sun exposure. Luckily, it rarely metastasizes, but may be locally destructive.
There are several histologic subtypes that influence morphology. The most common are:
Various clinical types include:
The BCC can take on many appearances. A pearly papule with telangiectasias on the face of an older person is classic. Other potential presentations include a blue papule (cystic BCC), a rodent ulcer, a waxy telangiectatic plaque and a red, scaly area (superficial BCC). The superficial BCC appears as a fixed, blanchable, ham-red lesion surrounded by sun-damaged skin. See also BCC in unusual sites and basosquamous cell carcinoma.
If you are going to treat the small BCC at the same visit as the biopsy, then the following does not apply. However, if you only need to establish the diagnosis and expect to recommend standard or Mohs surgery, then the following have been recommended:
A variety of treatments exist including curettage and electrodesiccation, curettage alone, standard surgery, Mohs surgery, imiquimod, photodynamic therapy, vismodegib (Erivedge), Odomzo and radiation. See treatment of BCC.
Any patient with a history of a BCC should be encouraged to have an annual total body skin examination.
After the diagnosis of the first BCC, the risk of developing a subsequent (metachronous) BCC is approximately 36% over the next 5 years [BJD 2017;177;1113]. Most metachronous BCCs develop within the first three years, but the risk remains elevated over time.
A recent placebo-controlled study of 386 patients who had been diagnosed with at least two skin cancers - such as basal cell carcinoma and squamous cell carcinoma - in the past five years, showed that taking 500 milligrams twice daily of nicotinamide (not nicotinic acid) reduced the subsequent risk of non-melanoma skin cancers by 23%. When patients stopped taking the supplements, their risk of getting skin cancer rose again about six months later.
A Danish study showed that increased coffee consumption was associated with a 30% relative risk reduction for diagnosis of a second BCC.
A prospective, randomized, double-blind, placebo-controlled study of acitretin 25 mg/day 5 days a week over 2 years did not show any reduction in the development of BCC in patients with a history of multiple BCCS [Cancer. 2012;118:2128].
Topical tretinoin and tazarotene have been shown to not be effective in preventing BCC [JID 2012;132:1583].
Per square inch, the nose is the most common place for a BCC.
Nodular BCC on the trunk.
The classic look of a superficial BCC. Uniform ham-red color.
Two BCCs here. The crusty, red plaque on the left and the pearly telangiectatic papule to the right.
Red nodule with telangiectasias. This lesion was a cystic BCC.
Pearly with telangiectasias on the scalp.
This crusted, non-healing papule was a morpheaform BCC.
Multiple superficial BCCs on the back (lots of sun damage as well).
BCC x 2 years. Courtesy of Michael O. Murphy, MD
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